About the Role

Brighton Health Plan Solutions is seeking a High Dollar Specialist to review high dollar claims for appropriate and accurate billing, pricing and adjudication.  This individual will play a key in the Quality Department and interact with many internal and external stakeholders.

Primary Responsibilities

+ Review high dollar claims to ensure claim was priced and billed correctly including implant and supply charges, observation room charges, units billed for drugs and procedures.

+ Review DRG for accuracy as compared to billed procedures, diagnosis/condition, age, etc.

+ Develop reporting mechanism to track pertinent claims information related to high dollar claims.

+ Collaborate review efforts with CMO, Legal and other departments as needed.

+ Coordinate efforts with external vendors as required.

Essential Qualifications

+ Significant experience in dealing with facility-based...